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M©NITING SYSTEM CERTIFICATION se By All Jurisdictions Within the State of Califo.mi Authority Cited: Chapter 6.7, Heath and Safety Code; Chapter 16, Division 3 Title 23, aria Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: RYDER 1071A Site Address: 3633 DUCK CREEK DRIVE City: STOCKTON CA Zip: 95215 Contact Phone No: 943-3213 Date of Testing/Service: 02/21/2007 Facility Contact Person: MARK ARMSTRONG Make/Model of Monitoring System: SIMPLICITY Work Order Number: 2247471 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: DSL -1 4�"�f Tank ID: DSL -2 X In -Tank Gauging Probe. Model: MAG -1 ZI In -Tank Gauging Probe. Model: MAGA X Annular Space or Vault Sensor. Model: 420 21 Annular Space or Vault Sensor. Model: 420 X Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 X Fill Sump Sensor(s). Model 208 Fill Sump Sensor(s). Model: 208 X Mechanical Line Leak Detector. Model: LD2000 )( Mechanical Line Leak Detector. LD2000 Model: _ Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: ANNUNCIATOR Tank OvefIlfHigh-Level Sensor. Model: ANNUNCIATOR Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). Tank ID: Tank ID: In -Tank Gauging Probe. Model: MAGA In -Tank Gauging Probe, Model: MAG -1 X Annular Space or Vault Sensor. Model: 420 71 Annular Space or Vault Sensor. Model: 420 X Piping Sump/Trench Sensor(s), Model: 208 X Piping Sump/Trench Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverfilllHigh-Level Sensor. Model: ANNUNCIATOR Tank Overfill/High-Level Sensor. Model: Other (specify equipment type and model in Section E on page 2). Other (specify equipment type and model in Section E on page 2). Dispenser : 112 Dispenser ID: 314 X❑ Dispenser Containment Sensor(s) Model: 208 X Dispenser Containment Sensor(s) Model: 208 X� Shear Valve(s). X Shear Valve(s) ElDispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 1 -SLAVE Dispenser ID: 2 -SLAVE 0 Dispenser Containment Sensor(s) Model: 208 Q Dispenser Containment Sensor(s). Model: 208 ElShear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 4 -SLAVE Dispenser ID: X❑ Dispenser Containment Sensor(s) Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). If the facility contains more tanks or dispensers, copy this form. include Intormatlon Tor every tanK ano olspenser at the racmty. C. Certification I certify that the equipment identified in this document was inspectedlserviced in accordance with the manufacturers' guidelines. Attached to this certification is information (e.g manufacturers' checklists) necessary to verify that this information is correct. and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): FX system set-up XD Alarm history report Technician Name (print): HEATH MCEVER Certification No.: A27562 Signature: 4�"�f License. No.: Testing Company Name:Tanknology Phone No.: (800) 8004633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 02/21/2007 Page 1 of 3 Based on CA form dated 03101 Monitoring System Certification